CCDS Certification: Overview and FAQ

Earning a certification can affirm your skills as a clinical documentation specialist while helping you stay updated on changes in medical coding. Looking for options? A Certified Clinical Documentation Specialist (CCDS) certification could give your career a leg up. Here’s what to know about it.

What Does a Clinical Documentation Specialist Do?

A clinical documentation specialist (CDS) combs through medical records to ensure that facilities and providers comply with regulations. This is different from a nursing informaticist or data analyst, who focuses on improving documentation systems and patient outcomes.

This role is best suited for professionals with both clinical and technical skills, so it could be perfect for RNs, NPs, nurse coders, and other nursing professionals. Additionally, it’s one of the more common remote nursing jobs.

If you’re new to the CDS field, you might be curious about the roles and responsibilities that a CCDS is suited for. Essential skills in the CDS role include:

• Being a reference for clinicians and administrators when they have questions about documentation standards.
• Partnering with different clinical teams to improve care metrics and documentation.
• Tracking compliance with Medicare and Medicaid standards.
• Auditing charts to ensure they are accurate.
• Generating and analyzing reports to find opportunities for improvement.
• Communicating with other departments such as coding, compliance, risk management, quality, and finance.

What Is CCDS Certification?

CCDS stands for Certified Clinical Documentation Specialist, and it’s one of the leading credentials for those who work as clinical documentation specialists. CCDS is targeted toward specialists who work for acute care facilities, and it’s offered by the Association of Clinical Documentation Integrity Specialists (ACDIS).

Inpatient documentation specialists typically work with chart data for patients who are currently in the hospital, or who have been discharged, but who haven’t been billed for their stay yet. Being a CDS requires knowledge of anatomy and physiology, coding regulations, medical ethics, pharmacology, and more.

Who Can Become a CCDS?

This certification is for experienced CDS professionals who are seeking to affirm their skills and elevate their knowledge base in medical documentation. To qualify for CCDS, you’ll need to fall into one of the following categories:

• An RN, RHIA, RHIT, MD, or DO with 2 years of experience as a CDS in an inpatient facility using the U.S. IPPS system.
• Someone who holds an associate degree or equivalent in an allied health occupation, which must include college-level courses in medical terminology and human anatomy and physiology. Must have 3 years of inpatient CDS experience.
• Someone with formal education in medical terminology, human anatomy and physiology, and pathophysiology, or possess the AHIMA CCS or CCS-P credential. Must have at least 3 years of experience as a CDS in an inpatient facility.

What Does CCDS Certification Cost?

Here’s a breakdown of what you can expect to pay to become a CCDS, depending on which group you fall into:

• ACDIS members: $280
• Non-members: $380

CCDS Certification Salary: Ranges for Clinical Documentation Specialists

According to ACDIS, most clinical documentation improvement professionals make between $80,000–$89,999 per year. Their data also shows that CCDS professionals are likely to earn more than that, with salaries around $100,000 per year.

How to Get a CCDS Certification: 3 Steps

Ready to get started on this new credential? Once you’ve met the requirements to be certified, follow these steps to earn your CCDS.

To prepare for the CCDS exam, you might want to take a third-party course or program. A CCDS certification course should help prepare you for work in this specialty role.

Step 1: Apply for The Exam

Start by creating an application on the ACDIS website. You’ll need to enter your work history and education background. If you need to leave your application and return to it later, you can save a draft. You’ll get an email from ACDIS, and you can restart your application using the button provided.

Once your application is processed, you’ll get instructions for scheduling the exam in your email. You have 90 days from the date your name is submitted in Prometric to schedule and take the exam, so don’t delay once you get the email. You’ll pay the fee when you schedule your exam.

Step 2: Pass the CCDS Exam

To pass the exam, you’ll need to get 88 questions correct out of 120 that are scored. You might want to register for a review course or buy a study guide to ensure you’re prepared. The exam covers topics including:

• Healthcare regulations, documentation, and reimbursement requirements related to the IPPS.
• Anatomy and physiology, pathophysiology, pharmacology, and medical terminology.
• Medical record documentation.
• Healthcare documentation improvement program analysis.
• Communication skills.
• Professionalism, ethics, and compliance.
• The impacts of reportable diagnoses on care quality.

Step 3: Receive Your CCDS

Once you pass the exam, congratulations! You’re a certified clinical data specialist. Your name will be added to the ACDIS directory of credential holders, and you can now list CCDS behind your name and other credentials.

Maintaining your knowledge and recertifying is an essential element of certification. You’ll need to apply for recertification for CCDS every two years by the anniversary date of when you passed the exam.

You’ll need to complete 30 hours of continuing education to renew. The recertification fee is $125 for members and $225 for nonmembers. You’ll have a 45-day grace period after your recertification date, but after that, there is a $150 late fee.

CCDS Credential FAQs

Are there other certifications for clinical documentation specialists?

Yes. There are some other clinical documentation certifications you might consider:

• Certified Clinical Documentation Specialist-Outpatient (CCDS-O)
• Certified Documentation Integrity Practitioner (CDIP)
• Clinical Documentation Improvement Apprentice (CDI Apprenticeship)
• Leadership in CDI Certificate

Is the CCDS exam hard?

If you prepare well for the exam, you’ll likely do well. ACDIS reports that about 77% of first-time test takers pass the CCDS exam.

Find Nursing Opportunities

If you’re researching the CCDS certification, you might be curious about roles for CDS professionals like you. IntelyCare can send you tailored job recommendations for nursing roles in your specialty.